TRANSFUSION SUPPORT IN HEPATOBILIARY AND PANCREATIC SURGERIES

Transcription

1 TRANSFUSION SUPPORT IN HEPATOBILIARY AND PANCREATIC SURGERIES Dr.K.C.Usha Professor & Head Dept: Of Transfusion Medicine & Director, Model Blood Bank Government Medical College Trivandrum,Kerala

2 INTRODUCTION Blood loss : major complication Multifactorial origin Large differences in Tx practices Incidence of Tx approximately 20 % - 30 % Females require less Tx Liberal Tx harmful to patient Requirements exceed volume collected

3 INTRODUCTION Contd Over crossmatching bld stock Wastage of resources Pre-op Hb best predictor of Tx Assess individualized Tx requirements PT/aPTT : not predict bleeding / thrombosis products required TEG / ROTEM not always reliable

4 FACTORS LEADING TO TRANSFUSION Low pre-op Hb Primary disease & stage at diagnosis Pre-existing coagulation disorders Other co-morbidities Pre-op platelet count sing age Types of procedure

5 FACTORS LEADING TO TRANSFUSION Contd Technical issues Surgeon s expertise Re-do surgeries Length of cold ischemia Tumor size > 3.5 cm Extended resection of liver( 5+ segments) S.Creatinine & Blood Urea levels

6 sed BLOOD LOSS Highly vascular matrix of liver Location of pancreas near major vessels Tracking of platelets in liver sinusoids Thrombocytopenia Portal Hypertension Coagulation disturbances Release of heparinoids & tissue Plasminogen Activator ( tpa ) Fluid replacement dil. coagulopathy

7 HEMOSTATIC CHANGES IN LIVER DISEASES Basically related to underlying disorder Liver failure Cirrhosis Cholestasis Coagulopathies Splenomegaly

8 HEMOSTATIC CHANGES IN LIVER DISEASES Contd Failure to synthesize coagulation factors II, VII, IX, X Coagulopathy with PT & aptt Cholestasis Vitamin K synthesis Platelet Count Thrombopoetin deficiency Splenomegaly Hyperfibrinolysis

9 MEASURES TO BLOOD LOSS Improve Sx /Anaesthetic techniques Blood sampling in pediatric cases A/c Intraop hemodilution Blood salvage from surgical sites Introduction of Micro Fat Emboli Denatured Proteins Free Hb Platelet Aggregates Leucocyte aggregates

10 MEASURES TO BLOOD LOSS Contd Salvaged blood ARDS Renal failure Washing collected RBC complications in CVP ; blood loss Low CVP venous return cardiac output peripheral tissue oxygenation Secondary damage to kidney Intraoperative fluid restriction Pharmacological strategies

11 PHARMACOLOGICAL STRATEGIES Pre-op Early use of erythropoeitin Fe supplimentation Multi vitamin & Folic acid Intra & peri-op Prompt mx of hyperfibrinolysis Two types of antifibrinolytics Lysine analogues EACA Tranexamic Acid (TA) Serine Protease Inhibitors Aprotinin

12 Epsilon Amino Caproic Acid (EACA) Synthetic lysine analogue Prevents conversion of Plasminogen Plasmin Associated renal complications A/c Tubular Necrosis renal failure

13 TRANEXAMIC ACID Synthetic derivative of Lysine Plasmin mediated conversion of fibrinogen fibrin Inhibits action of plasminogen & plasmin 6 10 times more potent than EACA Well tolerated Less adverse effects

14 APROTININ Hemostatic effects comparable to TA Intra-op blood loss Rate of thrombosis Renal dysfunction Sometimes death Temporarily withdrawn from market

15 OTHER PHARMACOLOGICAL AGENTS Fibrin glue Gel foam Epinephrine sponges Avitene

16 ROLE OF TX SERVICES a) Type & Screen b) Crossmatch

17 TYPE & SCREEN Patient s blood grouping Screening for any irregular abs Donor units not removed from stock No resource wastage Not labour intensive

18 CROSSMATCH Designated donor units xmatched Reserved for particular patient CT Ratio More costly Resource intensive Available units from stock Chance for expiry of units Wasting limited resources

19 ADVERSE EFFECTS OF TRANSFUSION FNHTR Hemolytic Tx reaction TRIM TACO TRALI TAGVHD TTDs

20 MSBOS MSBOS policies vary between hospitals Patient specific factors not considered Considers only type of surgeries Not completely reliable/adequate Ideally consider surgical and patient variables

21 MODIFICATION OF MSBOS Surgical Blood Ordering Equation SBOE Patient Specific Blood Ordering System PSBOS Both consider surgical & patient factors

22 GOAL OF BLOOD MANAGEMENT Exposure to allogenic blood Reduce overall need for Tx Reduce cost Individualized patient risk assessment Improve medical/ functional outcomes Develop global strategy for blood management

23 UPTO DATE GUIDELINES Peri-op antifibrinolytic therapy Timely detection of coagulation defects TEG/ROTEM Critical Hb threshold 8 gm/dl for RBC Tx Tx of platelets if count < 50,000/µL Fibrinogen trigger values g/l Fibrinogen conc: mg/kg

24 UPTO DATE GUIDELINES Contd Cryoprecipitate 5ml/Kg No clear recommendation Tx of FFP / Platelets Use of Desmopressin in absence of Hemophilia Not depend on PT / aptt in cirrhotic patients Fluid restriction Low CVP Low Tx rates in liver transplantation

25 STUDY IN MCH,TRIVANDRUM Study Design : Cross Sectional study Study Setting : Dept. of Transfusion Medicine & Surgical Gastroenterology Study duration: one and a half years Sample size: 201 Liver Transplant : 1 Other conditions : 200

26 LIVER TRANSPLANTATION Male patient Age : 58 years Child Pugh Classification : B Blood Group : A Positive

27 LIVER TRANSPLANT - TRANSFUSION DETAILS DATE PRC FFP PC CRYO 23/5/2016 (D1) REOPENED ON DAY 2 24/5/2016 (D2) /5/2016 (D3) 2 27/5/2016 (D5) /5/2016 (D6) 3 29/5/2016 (D7) 5 30/5/2016 (D8) 3 8 2/6/2016 (D11) 3 3/6/2016 (D12) 2 8/6/2016 (D17) 2 EXPIRED ON 18 TH DAY OF SURGERY

28 CASES OTHER THAN LIVER TRANSPLANT

29 DIAGNOSIS

30 COMORBIDITIES Diabetes melitus % No Comorbidities %

31 PERCENTAGE DISTRIBUTION ACCORDING TO COMORBIDITIES

32 SURGERIES Whipple s Procedure % Frey s Procedure % Gastrojejunostomy 7 3.5% Hepatectomy %

33 TYPES OF SURGERIES

34 AMERICAN SOCIETY OF ANESTHETIST S PHYSICAL STATUS SCORE (ASA PS SCORE) ASA PS Classification Definition ASA 1 A normal healthy patient ASA 2 ASA 33 ASA 44 A patient with mild systemic diseases without substantive functional limitations A patient with severe systemic diseases with substantive functional limitations A patient with severe systemic diseases with substantive functional limitations A patient with severe systemic disease that is a constant threat to life A patient with severe systemic disease that is a constant threat to life ASA 5 A moribund patient who is not expected to survive without the operation ASA 6 A declared brain dead patient whose organs are being removed for donor purposes

35 PRBC Tx BASED ON DIAGNOSIS

36 PRBC Tx BASED ON BIOCHEMICAL PARAMETERS Blood Urea >/= 20 mg /dl 30.7% received Tx < 20 mg/dl 16.3% received Tx S.Creatinine >/= 1.2 mg/dl 35.7% received Tx < 1.2 mg/dl 23.6% received Tx

37 PRBC Tx BASED ON INFUSION OF IV FLUIDS IV Fluid given 77.4 % received Tx IV Fluid not given 55.6% received Tx

38 FFP Tx BASED ON DIAGNOSIS

39 FFP Tx BASED ON DIAGNOSIS

40 INFERENCE FROM OUR STUDY Factors influencing Tx Etiology of disease Comorbidities Intraop IV fluid infusion Hematological parameters Biochemical parameters BMI Tx Number of Tx Serum Creatinine Blood Urea IV fluid use Hb < 8 gm/ dl PCV < 24 %

41 OTHER STUDIES Global studies in progress How to Tx requirement a) Cholestatic Liver Disease Consortium CLiC Launched in 2003 in N.America Now part of ChiLDREN Childhood Liver Disease Research And Education Network b) Biliary Atresia Research Consortium BARC Launched in US Analyse results of various studies from 1997

42 CONCLUSION Large diff: in Tx practice between hospitals Preop identification of patients at risk Follow institutional guidelines to Tx Adopt restrictive Tx strategies Decision for Tx based on Patient level data Procedure specific information Coagulopathy due to Trauma of Sx Underlying disorders Over usage of IV fluid Improve surgical & anaesthetic techniques Tx rate : morbidity & mortality Lack of evidence based Tx protocols Paucity of randomized clinical trials Periop morbidities MAJOR CHALLENGE

43 TAN Q